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\begin{document}

\title{Evaluation of aphasia in a culturally and linguistically diverse
context: Practices of and challenges faced by speech-language
pathologists}



\author[1]{Fatimah Hani Hassan}%
\author[2]{Pei-Whey Heng}%
\author[3]{Rahayu Mustaffa Kamal}%
\affil[1]{Universiti Kebangsaan Malaysia}%
\affil[2]{Affiliation not available}%
\affil[3]{International Islamic University Malaysia - Kuantan Campus}%


\vspace{-1em}



  
  \date{May 17, 2024}


\begingroup
\let\center\flushleft
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\selectlanguage{english}
\begin{abstract}
Rationale, aims and objectives: Cultural and linguistic diversity is a
major challenge faced by speech-language pathologists (SLPs) in
conducting evaluation of aphasia, especially in low-resource regions.
Without proper consideration of cultural and linguistic issues when
adapting English-based language tests to other languages, performance of
individual with aphasia may not be valid and reliable. The present study
was conducted: (a) to identify the practices of SLPs in conducting
aphasia evaluation in Malaysia, which is a country consisting of
multiethnic populations, and (b) to determine challenges faced by SLPs
when conducting aphasia evaluation involving a diverse group of
individuals. Methods: An online survey was distributed to SLPs who are
practicing in Malaysia involved in the management of aphasia during the
period of data collection. The questionnaire was developed to gather
data on participants' background, their practices in evaluating people
with aphasia, and challenges that they face related to aphasia
evaluation. Proportions were calculated for each item in the
questionnaire to determine patterns related to background information,
SLP practices and related challenges. Results: Malaysian SLPs were found
to gather information about their patients via interviews with
caregivers, medical records, and direct testing and observation.
Abilities of people with aphasia that were consistently reported to be
assessed frequently include auditory language comprehension, verbal
expression, repetition of words and sentences, and social communication.
Two major challenges identified were linguistic barrier and lack of
standardized assessment tools for aphasia evaluation. Conclusions: There
are some similarities in terms of SLP practices and challenges faced by
the participants in comparison with other studies conducted in diverse
contexts. Issues related to cultural and linguistic diversity
complicates the development of appropriate resources for aphasia
evaluation. Consideration of those issues in development of original and
adapted evaluation tools may improve the accuracy of diagnosis,
identification of severity, and planning of intervention.%
\end{abstract}%



\sloppy


\textbf{Title Page}

Article title: Evaluation of aphasia in a culturally and linguistically
diverse context: Practices of and challenges faced by speech-language
pathologists

Running title: Evaluation of aphasia in a CLD context (Character count:
38 characters)

Authors and affiliations:

\begin{enumerate}
\tightlist
\item
  Author name (corresponding author): Fatimah Hani Hassan Affiliation:
  Faculty of Health Sciences, Universiti Kebangsaan Malaysia Email:
  fatimahhani@ukm.edu.my Postal address: Center for Rehabilitation and
  Special Needs Studies, Faculty of Health Sciences, Universiti
  Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur,
  MALAYSIA. Telephone number: +603-9289-5011
\item
  Author name: Pei Whey Heng Affiliation (during study period): Faculty
  of Health Sciences, Universiti Kebangsaan Malaysia Current
  affiliation: KPJ Damansara Specialist Hospital
\item
  Author name: Rahayu Mustaffa Kamal Affiliation (during study period):
  Faculty of Health Sciences, Universiti Kebangsaan Malaysia Current
  affiliation: International Islamic University of Malaysia
\end{enumerate}

Funding information: There is no funding received for the study

Conflict of interest statement: All authors declare that there is no
conflict of interests associated with the study.

\section*{Structured Abstract (word count: 300
words)}

{\label{structured-abstract-word-count-300-words}}

Rationale, aims and objectives: Cultural and linguistic diversity is a
major challenge faced by speech-language pathologists (SLPs) in
conducting evaluation of aphasia, especially in low-resource regions.
Without proper consideration of cultural and linguistic issues when
adapting English-based language tests to other languages, performance of
individual with aphasia may not be valid and reliable. The present study
was conducted: (a) to identify the practices of SLPs in conducting
aphasia evaluation in Malaysia, which is a country consisting of
multiethnic populations, and (b) to determine challenges faced by SLPs
when conducting aphasia evaluation involving a diverse group of
individuals.

{\label{rationale-aims-and-objectives-cultural-and-linguistic-diversity-is-a-major-challenge-faced-by-speech-language-pathologists-slps-in-conducting-evaluation-of-aphasia-especially-in-low-resource-regions.-without-proper-consideration-of-cultural-and-linguistic-issues-when-adapting-english-based-language-tests-to-other-languages-performance-of-individual-with-aphasia-may-not-be-valid-and-reliable.-the-present-study-was-conducted-a-to-identify-the-practices-of-slps-in-conducting-aphasia-evaluation-in-malaysia-which-is-a-country-consisting-of-multiethnic-populations-and-b-to-determine-challenges-faced-by-slps-when-conducting-aphasia-evaluation-involving-a-diverse-group-of-individuals.}}

Methods: An online survey was distributed to SLPs who are practicing in
Malaysia involved in the management of aphasia during the period of data
collection. The questionnaire was developed to gather data on
participants' background, their practices in evaluating people with
aphasia, and challenges that they face related to aphasia evaluation.
Proportions were calculated for each item in the questionnaire to
determine patterns related to background information, SLP practices and
related challenges.

{\label{methods-an-online-survey-was-distributed-to-slps-who-are-practicing-in-malaysia-involved-in-the-management-of-aphasia-during-the-period-of-data-collection.-the-questionnaire-was-developed-to-gather-data-on-participants-background-their-practices-in-evaluating-people-with-aphasia-and-challenges-that-they-face-related-to-aphasia-evaluation.-proportions-were-calculated-for-each-item-in-the-questionnaire-to-determine-patterns-related-to-background-information-slp-practices-and-related-challenges.}}

Results: Malaysian SLPs were found to gather information about their
patients via interviews with caregivers, medical records, and direct
testing and observation. Abilities of people with aphasia that were
consistently reported to be assessed frequently include auditory
language comprehension, verbal expression, repetition of words and
sentences, and social communication. Two major challenges identified
were linguistic barrier and lack of standardized assessment tools for
aphasia evaluation.

{\label{results-malaysian-slps-were-found-to-gather-information-about-their-patients-via-interviews-with-caregivers-medical-records-and-direct-testing-and-observation.-abilities-of-people-with-aphasia-that-were-consistently-reported-to-be-assessed-frequently-include-auditory-language-comprehension-verbal-expression-repetition-of-words-and-sentences-and-social-communication.-two-major-challenges-identified-were-linguistic-barrier-and-lack-of-standardized-assessment-tools-for-aphasia-evaluation.}}

Conclusions: There are some similarities in terms of SLP practices and
challenges faced by the participants in comparison with other studies
conducted in diverse contexts. Issues related to cultural and linguistic
diversity complicates the development of appropriate resources for
aphasia evaluation. Consideration of those issues in development of
original and adapted evaluation tools may improve the accuracy of
diagnosis, identification of severity, and planning of intervention.

{\label{conclusions-there-are-some-similarities-in-terms-of-slp-practices-and-challenges-faced-by-the-participants-in-comparison-with-other-studies-conducted-in-diverse-contexts.-issues-related-to-cultural-and-linguistic-diversity-complicates-the-development-of-appropriate-resources-for-aphasia-evaluation.-consideration-of-those-issues-in-development-of-original-and-adapted-evaluation-tools-may-improve-the-accuracy-of-diagnosis-identification-of-severity-and-planning-of-intervention.}}

\textbf{Keywords:} aphasia; speech-language pathologists; evaluation;
language test; survey; Malaysia; diversity

\subsection*{}

{\label{section}}



\textbf{Main Text} (word count: 4957 words)

\section*{Introduction}

{\label{introduction}}

\subsection*{Evaluation and Diagnosis of
Aphasia}

{\label{evaluation-and-diagnosis-of-aphasia}}

Aphasia is an acquired language disorder that occurs due to brain injury
on the language-dominant hemisphere \textsuperscript{1}. A thorough
evaluation is crucial in making diagnosis of aphasia, as well as
determining appropriate aphasia treatment, including treatment focus,
frequency, and length \textsuperscript{2,3}. The American
Speech-Language-Hearing Association recommended that speech-language
pathologists (SLPs) complete a thorough evaluation by collecting valid
and reliable information from multiple sources, including direct
testing, observations, and reports \textsuperscript{3}. Following a
systematic review of clinical practice guidelines for aphasia
rehabilitation, Shrubsole and colleagues proposed (in relation to the
evaluation of aphasia) that SLPs: (a) ensure the validity and
reliability of assessment tools, (b) collect information that will lead
to the development of meaningful and relevant treatment goals, and (c)
actively communicate with families, caregivers, co-workers and other
healthcare professionals to determine the severity, needs and issues
faced by individuals with aphasia in various
situations\textsuperscript{4}.

Based on the World Health Organization's International Classification of
Functioning, Disability and Health Framework (WHO ICF), it was
recommended that SLPs focus on multiple facets during aphasia
evaluation, such as the individual's background, levels of language
capabilities, impacts of communication impairment, and factors that
facilitate or impede recovery of aphasia \textsuperscript{3}. While it
is important to cover all facets of the framework when evaluating people
with aphasia (PWA), it is important to note that aphasia is
characterized by language skill deficits \textsuperscript{5}. PWA has
difficulties in comprehending and producing language at various
linguistic levels (i.e., lexical-semantic, syntax, and discourse), which
may be associated with impaired language processing \textsuperscript{1}.
Language impairment of aphasia occurs regardless of the modalities used
for transmitting or receiving language, including
auditory-verbal/spoken, textual, and sign language
modes\textsuperscript{2}. Due to difficulties in comprehending and
producing language in various modalities, communication of PWA with
other are negatively affected and requires compensatory
support\textsuperscript{6}. Language functions may be improved through
direct intervention that is based on evaluation findings of language
functions\textsuperscript{7}.

\subsection*{Language Evaluation in Culturally and Linguistically Diverse
Contexts}

{\label{language-evaluation-in-culturally-and-linguistically-diverse-contexts}}

When conducting language and communication assessments involving people
with diverse background, previous studies have reported that SLPs face
challenges in accumulating reliable and valid assessment findings.
Impact on reliability and validity of assessment findings may arise due
to multiple languages used by the client \textsuperscript{8}. In other
circumstances, clinicians may be unable to speak languages and/or
appreciate beliefs, customary practices and cultural etiquette of
clients and their families \textsuperscript{9}. These limitations may
result in biased judgment that may lead to inappropriate treatment
programs for individuals with communication
disorders\textsuperscript{10}.

Malaysian population consists of multiple ethnic groups, including
Malays, indigenous people, Chinese, Indians, and
Eurasians\textsuperscript{11}. Malays and indigenous people have
occupied the Malaysian regions for centuries, while those with Chinese,
Indian, and Eurasian backgrounds are the descendants of immigrants
during the colonial period \textsuperscript{12}. Since the independence
of the nation, the Malay language has been employed as the national
language and formally taught in schools; however, this language is
mainly used for formal government-related affairs and for communication
among the Malays \textsuperscript{13}. Variations of Chinese dialects,
Tamil, English and more than 80 indigenous languages are continued to be
used throughout the nation by various ethnic groups
\textsuperscript{13,14}. In addition, various ethnic groups preserve
their unique customs and etiquettes \textsuperscript{15}. Interestingly,
some values are being shared across cultures due to co-existence of
different ethnicities for many years \textsuperscript{16}.

Due to cultural and linguistic diversity in Malaysia, SLPs are likely to
experience difficulties in ensuring the validity of finding from
language and communication evaluations. Previous research demonstrated a
lack of psychometrically sound assessment tools in Malaysian local
languages \textsuperscript{17,18}. A lack of appropriate tools for local
populations was reported to be a common challenge across various
disorders \textsuperscript{19}. To reduce the dearth of resources for
aphasia evaluation, Van Dort and colleagues adapted the Boston Naming
Test into the Malay language; however, in the adapted Malay version,
only 48.3\% of the original items were found to be culturally
appropriate for the Malaysian Malay population \textsuperscript{20}.
Other items were found to be less relevant to Malaysian experiences
(e.g., pretzel, acorn, and wreath).

In order to improve the present situation, we aim to uncover general
practices of Malaysian SLPs in conducting evaluation of aphasia within
the Malaysian contexts, in terms of the components of aphasia
evaluation, methods to gather language-based data, and contexts in which
aphasia evaluation was conducted. In addition, we aim to determine the
extent to which diversity-related challenges act as a barrier for
successful evaluation of aphasia.

\section*{Methods}

{\label{methods}}

\subsection*{Study design}

{\label{study-design}}

A cross-sectional online survey was employed. The survey consisted of
multi-choice items, with an open-ended section for participants to add
responses that were not listed in the presented options.

\subsection*{Participants}

{\label{participants}}

An invitation email was sent to the members of Malaysian Association of
Speech and Hearing and Malaysian Speech-Language Therapist Association.
Participants received background and explanation about the study through
the email. An online link of the survey was extended to potential
participants who replied to the invitation email and indicated their
involvement in aphasia management. All participants met the following
inclusion criteria: (a) having a qualification to practice as an SLP in
Malaysia and (b) being involved in clinical management of aphasia during
data collection period. Participants were requested to provided online
consent before completing an online questionnaire.

\subsection*{Materials}

{\label{materials}}

An online questionnaire was developed for the study based on previous
studies that focus on SLP practices (Joginder Singh \emph{et al} . 2011;
Mustaffa Kamal \emph{et al} . 2012; Simmons \emph{et al} . 2003;
Taylor\emph{et al} . 2009). Three SLPs who primarily focus their
clinical work on aphasia management were involved as panel experts for
evaluation face and content validity, as well as overall presentation of
the survey. Based on their recommendation, we included additional
questions and modified sentence structure and item sequence. The
questionnaire consisted of three sections as shown in Table 1.

{[}Table 1{]}

\subsection*{Data analyses}

{\label{data-analyses}}

Percentages were obtained for categorical data in all sections of the
questionnaire. For Section II, percentages were calculated based on
Likert scale points. Five points on the Likert scale were recategorized
into three levels of frequency: ``Never'' for the first point, ``Less
Frequent'' for the second and third points, and ``More Frequent'' for
the fourth and fifth points. Three levels of consistency (Highly
Consistent, Moderately Consistent, and Inconsistent) were also
determined for each level of frequency of assessment activities. A
specific aspect or activity was considered to be Highly Consistent (HC)
when at least 80\% of participants agree on considering an aspect or
conducting an activity at the same frequency level. An agreement level
of 50-79\% on a specific aspect or activity was considered to be
Moderately Consistent (MC). Inconsistent (IC) level was considered for
an agreement level that was less than 50\% (Trochim and Donelly 2007,
Mustaffa Kamal \emph{et al} . 2012). In addition, nine types of
challenges were presented to participants. The proportions of
participants who reportedly have been facing specified challenges were
calculated.

\section*{Results}

{\label{results}}

\subsection*{Participants' demographic
information}

{\label{participants-demographic-information}}

The online survey was distributed to 107 Malaysian SLPs who fit the
inclusion criteria. A total of 32 participants completed the survey,
which resulted in a response rate of 29.9\%. Participants' demographic
information is summarized in Table 2.

{[}Table 2{]}

\textbf{Frequency and consistency of aphasia assessment aspects and
activities.} The level of frequency and consistency were identified for
the following aspects and activities: (a) documentation of case history
and background information, (b) components of aphasia assessment, (c)
methods of language and communication skills evaluation, and (d)
contexts of aphasia evaluation. Table 3 summarizes the frequency and
consistency levels for each aspect or activity. Practices that were to
be conducted frequently and consistently (rated by more than 80\% of the
participants) are:

\begin{enumerate}
\tightlist
\item
  Documentation of case history via interview and medical records
\item
  Evaluation of auditory language comprehension and spoken
  language/verbal expression
\item
  Evaluation of repetition of words and sentences
\item
  Evaluation of pragmatic and social skills
\item
  Unstructured observation of language and communication functions
\item
  Application of informal assessment approach
\item
  Evaluation of aphasia in clinical settings
\end{enumerate}

{[}Table 3{]}

\textbf{Challenges in aphasia assessment.} The challenges were grouped
into three categories, which are barriers related to cultural-linguistic
diversity, limitation of support and resources, and limitation of
clinical competency among SLPs in aphasia evaluation. The proportion for
each challenge as rated by the participants is shown in Table 4. Two
types of challenges were identified to be experiences by more than half
of the participants, which include: (a) language differences between PWA
and clinicians, and (b) lack of standardized tool for aphasia
evaluation.

{[}Table 4{]}

\section*{Discussion}

{\label{discussion}}

\subsection*{Aphasia Evaluation: Practices of Malaysian
SLPs}

{\label{aphasia-evaluation-practices-of-malaysian-slps}}

In the present study, we revealed practices of SLPs and related issues
pertaining to the evaluation of aphasia. In general, it was found that
SLPs reported consistency of practices in certain aspects of aphasia
evaluation. Four trends were identified related to their aphasia
evaluation practices.

Firstly, SLPs were found to consistently obtain case history and
background information through patient/caregiver interviews and medical
records. As mentioned earlier, Shrubsole and colleagues recommended for
the involvement and collaboration of SLPs with PWA and individuals who
are relevant in their intervention. Involvement of family and caregivers
in speech-language management of aphasia is crucial to ensure positive
intervention outcomes following carry-over of SLPs recommendation in
home environment \textsuperscript{21}. The results of this study may
indicate that Malaysian SLPs are aware of the importance of family
involvement in successful aphasia care. Unlike family involvement,
collaboration of SLPs with other healthcare professionals was less
consistent. Malaysian SLPs seemed to rely more on medical records as
compared to direct engagement with other healthcare professionals.
Direct communication with professionals from other disciplines may
support in-depth understanding of patients' conditions, roles of SLPs in
aphasia intervention, and gain perspectives of the professionals
regarding needs, facilitators and barriers that may impact aphasia
recovery \textsuperscript{22}. It is important to note that most of the
participants worked in acute public hospitals. In this type of setting,
SLPs and non-SLP professionals tend to have heavy caseloads and might
only confer on select cases \textsuperscript{23}.

Secondly, SLPs were found to focus their evaluation on auditory language
comprehension, spoken language/verbal expression, repetition of words
and sentences, and pragmatic/social communication skills. Since aphasia
is affecting the ability of PWA to understand, produce, and use language
for communication \textsuperscript{2}, it was expected that SLPs direct
their evaluation on those abilities. Across the evaluation components
rated by the participants, all of them unanimously reported that
pragmatic and social communication skills are consistently evaluated.
Findings from pragmatic and social communication assessments may inform
SLPs regarding competency of PWA to use language when communicating with
others \textsuperscript{24}. Although reading comprehension and written
expression abilities are also defining characteristics of
aphasia\textsuperscript{2}, it is surprising that SLPs demonstrated
lower consistency in evaluating those abilities. Lack of consistency in
evaluating reading and writing abilities may be related to the limited
available time for SLPs to complete assessments during the initial
session. In other countries, limited time with individual patients have
reportedly been a challenge for SLPs, not only in assessing PWA, but
also in providing treatment \textsuperscript{25--27}. While initial
evaluation findings are useful for determining the presence and severity
of aphasia, continuous evaluations must be conducted to ensure provision
of appropriate treatment based on the needs of individuals with
aphasia\textsuperscript{2,28}. Language and communication abilities
among people with aphasia (PWA) have been proven to change with
time\textsuperscript{29}. Continuous assessment of aphasia also may
address components that have not been thoroughly evaluated during the
initial session.

Thirdly, SLPs were found to rely upon unstructured and informal means to
evaluate PWAs' language and communication abilities. Unlike the
practices of SLPs in Singapore (a neighboring country), the participants
reported moderate consistency in utilizing formal assessment tools,
which primarily aim to determine the skills that are impaired and the
extent of impairment. In the Singaporean study, more than 90\% of their
SLP participants utilized an assessment tools for evaluation of
aphasia\textsuperscript{30}. In the present study, only about 50\% of
the participants have been using formal assessment tools frequently,
while the remaining half either use the tools infrequently or not at
all. This may be due to the lack of standardized tools can be accessed
by SLPs, which has been identified by the participants as a common
challenge. Three tools were found to be used in both Singapore and
Malaysia, which are the Boston Diagnostic Aphasia Examination
(BDAE)\textsuperscript{31}, Psycholinguistic Assessments of Language
Processing in Aphasia (PALPA) \textsuperscript{32} and Comprehensive
Aphasia Test (CAT) \textsuperscript{33}. Although these tools are more
often used in both countries, SLPs utilized those tools minimally. More
consistently, Malaysian SLPs have been employing informal approach to
gather evaluation findings.

Finally, evaluation of aphasia was found to be primarily limited to
clinical settings. This may be due to nature of service provision at
SLPs' workplaces. More than 80\% of study participants reported to work
in acute hospitals, which is a trend that has been reported in other
studies \textsuperscript{17,18,34,35}. According to Ahmad and colleague,
the Malaysian Ministry of Health has been a primary source of employment
for graduates of local SLP university programs, thus, many SLPs are
working in public hospitals through the country \textsuperscript{19}.
SLPs in acute public hospitals tend to serve individuals with
communication and/or swallowing impairments across the lifespan, which
result in high caseloads and limited time to engage with PWA in
non-clinical settings \textsuperscript{34}. Since aphasia affects
communication abilities of PWA, it has been noted that aphasia
evaluation that is conducted in social and personally-relevant
environment, such as their workplace and personal homes, may provide
critical information for designing an effective treatment
program\textsuperscript{36}.

\subsection*{Issues on Cultural and Linguistic Diversity in Aphasia
Evaluation}

{\label{issues-on-cultural-and-linguistic-diversity-in-aphasia-evaluation}}

Across the nine challenges presented in the survey, linguistic barriers
and lack of standardized resources were rated to be more common among
SLPs. As mentioned earlier, the Malaysian population consists of diverse
ethnic groups, who are using a variety of languages and/or dialects. A
huge majority of Malaysians are able to communicate in more than one
language \textsuperscript{13,14}. In the case of aphasia, proficiency of
one or more language may be affected differently, hence the need to
evaluate functioning of all languages used by PWA prior to the onset of
aphasia \textsuperscript{37,38}. Varied effects of language impairment
on PWAs' abilities in different languages may be due to the extent in
which one language is better preserved than another\textsuperscript{37}.
In addition, the age when one acquire the second and additional
languages have been found to influence aphasia recovery for that
particular language \textsuperscript{39}.

It can also be inferred that those two challenges (i.e., linguistic
barrier and lack of standardized language tools) are related. In
conducting language evaluation, SLPs commonly translate and adapt
assessment tools that has been developed and normed based on
English-speaking population \textsuperscript{30,37,40}. The complexity
of the processes involved in translating and adapting standardized
English language tools is well acknowledged \textsuperscript{41}.
Clinicians are required to consider various attributes associated with
diverse cultures, linguistic features (including semantics,
grammaticality, and syntactic structures) and factors that may influence
performance level in those test, such as item familiarity, word
frequency, and age of word acquisition \textsuperscript{40,42}. Because
linguistic and culture-related aspects must be considered in order to
adapt English tools to local languages, the progress of resource
development for aphasia evaluation tend to be slow, thus, affecting the
availability of standardized language tools for local populations.
Additionally, lack of expertise and financial support may also restrict
the progress in developing tools for aphasia
evaluation\textsuperscript{19,43}.

Experts have suggested strategies to address these challenges. One of
the strategies involve the adaptation of tools that are generally
neutral in terms of the stimuli used in testing \textsuperscript{44}.
For example, the Revised Token Test (RTT) \textsuperscript{45} primarily
includes basic colors, prepositions, and shapes for its language
stimuli. It is important to note that this strategy may not address all
issues related to cultural and linguistic diversity. In adapting the RTT
into standard Indonesian language, Jap and Arumsari found that the
usability of the adapted version is limited for individuals who are
using various other Indonesian dialects \textsuperscript{46}. Therefore,
assessment findings based on the adapted tests must be treated
cautiously.

Another strategy for addressing assessment of aphasia with multilingual
and culturally diverse population is related to the discourse analysis
approach, where language and communication samples are collected by SLPs
within and outside of clinical contexts \textsuperscript{47}. Discourse
analysis was found to provide SLPs with accurate diagnosis of aphasia,
as well as its types and severity \textsuperscript{48}. However,
discourse analysis requires training for SLPs to acquire specific skill
set in eliciting language and communication samples and analyze content
and linguistic characteristics accurately \textsuperscript{49}. Bryant
and colleagues found that even among SLPs who have been trained to
conduct discourse analysis, many did not apply the method due to time
constraint at their workplace \textsuperscript{49}.

Although cultural and linguistic issues related to aphasia evaluation
cannot be resolved immediately, strategies suggested by previous
researchers and experts can be applied with proper consideration. At the
same time, effort to develop assessment resources for diverse
populations must be enhanced and supported in order to speed up the
process. Building professional network may also encourage support among
SLPs via sharing resources, experience and methods that may be applied
relevant to the local contexts.

\subsection*{Limitation of the Study.}

{\label{limitation-of-the-study.}}

The present study only focused on evaluation of language functions in
aphasia assessment and challenges faced by SLPs related to it. Focus on
other aspects of evaluation was minimal. This study did not include the
practices of SLPs in the evaluation of access to communication for PWA
and impacts of aphasia on the lives of PWA. Future studies are needed
for discovering the frequency and extent of evaluation processes in
addressing all facets proposed in WHO ICF \textsuperscript{50}. Based on
the ICF, evaluation of aphasia must also include impacts of
communication impairment on the lives of PWA, as well as factors that
may affect aphasia recovery and opportunities for PWA to participate in
social and personally relevant activities, including management of
personal finances, involvement in hobbies before the onset of aphasia,
and recommencement of roles prior to aphasia in the context of family
and community. By looking at various psychosocial aspects, cultural
impacts on evaluation practices might be more visible. Participation of
PWA and their caregivers may also give better insights for improving
guidelines and protocols for aphasia evaluation.

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\section*{Acknowledgement}

{\label{acknowledgement}}

We thank Universiti Kebangsaan Malaysia for providing physical support
to conduct this study. We are grateful for the feedback given by faculty
members of the UKM Speech Sciences Programme to improve the quality of
the student. Finally, we extend our appreciate to all participants for
taking part in the study.

\textbf{Tables}

Table 1: Questionnaire sections and description\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
\begin{minipage}[b]{0.30\columnwidth}\raggedright\strut
Questionnaire section\strut
\end{minipage} & \begin{minipage}[b]{0.30\columnwidth}\raggedright\strut
Number of items\strut
\end{minipage} & \begin{minipage}[b]{0.30\columnwidth}\raggedright\strut
Description of section\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Section I: Participants' background\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
6\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
This section consists of multiple-choice questions to obtain
participants' background information, including academic qualification,
years of experience working as an SLP, types of clinical settings, and
clinical workload.\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Section II: Aphasia assessment practice\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
57\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
This section consists of 5-point Likert scale items that cover various
aspects and activities related to aphasia evaluation: Documentation of
case history and background information Components of language and
communication assessment Evaluation methods Contexts of evaluation\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Section III: Challenges faced by SLPs\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
This section consists of multiple-choice questions on challenges related
to linguistic and cultural diversity, resource limitation and competency
level.\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Table 2: Demographic information of participants\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
Demographic information & \% (\emph{n})\tabularnewline
\midrule
\endhead
\vtop{\hbox{\strut Highest academic qualification Bachelor's degree
(local university)}\hbox{\strut Master's degree (abroad university)}} &
96.9\% (31) 3.1\% (1)\tabularnewline
\vtop{\hbox{\strut Years of working experience Less than 3
years}\hbox{\strut 3 to 10 years}\hbox{\strut More than 10 years}} &
56.3\% (18) 31.2\% (10) 12.5\% (4)\tabularnewline
\vtop{\hbox{\strut Clinical setting Acute hospital (public and private
sectors)}\hbox{\strut Community-based clinic (non-profit organization
and university settings)}} & 84.4\% (27) 15.6\% (5)\tabularnewline
\vtop{\hbox{\strut Aphasia workload (of total workload) Less than
25\%}\hbox{\strut 25\% to 75\%}\hbox{\strut More than 75\%}} & 50.0 \%
(16) 40.6\% (13) 9.4\% (3)\tabularnewline
\bottomrule
\end{longtable}

Table 3: Level of frequency and consistency of aphasia assessment
aspects and activities\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
Assessment aspect and activity & Level of frequency (\%) & Level of
frequency (\%) & Level of frequency (\%) & Level of
consistency\tabularnewline
\midrule
\endhead
& Never & Less Frequent & More Frequent &\tabularnewline
Documentation of case history and background information PWA and
caregiver interviews Medical records Interprofessional discussions & 3.1
0.0 15.6 & 6.3 9.4 40.6 & \textbf{90.6} \textbf{90.6} 43.6 & \textbf{HC}
\textbf{HC} IC\tabularnewline
Components of aphasia assessment Auditory language comprehension
Identifying spoken single words Following simple instructions and
sentences Following complex instructions and sentences Reading
comprehension Identify alphabets and numbers Identify written words
Understand written sentences Lexical decision Spoken language/verbal
expression Object/picture naming Picture description Spontaneous speech
Automatized sequencing Verbal agility Melody and rhythm Written
expression Mechanics of writing Spelling Writing regular word Writing
irregular word Writing nonsense word Writing sentences Repetition Repeat
word Repeat sentence Repeat nonsense word Pragmatic/Social Communication
& 0.0 0.0 0.0 0.0 3.1 3.1 3.1 0.0 0.0 0.0 0.0 0.0 3.1 0.0 9.4 6.3 6.3
25.0 6.3 0.0 0.0 3.1 0.0 & 3.1 3.1 6.3 31.3 21.9 37.5 50.1 3.1 2.5 3.1
2.5 9.4 31.3 34.4 43.8 28.1 68.8 59.4 28.1 6.3 12.5 37.5 0.0 &
\textbf{96.9} \textbf{96.9} \textbf{93.7} 68.7 75.0 59.4 46.8
\textbf{96.9} \textbf{87.5} \textbf{96.9} \textbf{87.5} \textbf{90.6}
65.6 65.6 46.8 65.6 28.1 15.6 62.4 \textbf{93.7} \textbf{87.5} 59.4
\textbf{100.0} & \textbf{HC} \textbf{HC} \textbf{HC} MC MC MC IC
\textbf{HC} \textbf{HC} \textbf{HC} \textbf{HC} \textbf{HC} MC MC IC MC
MC MC MC \textbf{HC} \textbf{HC} MC \textbf{HC}\tabularnewline
Table 3 (continued) & Table 3 (continued) & Table 3 (continued) & Table
3 (continued) & Table 3 (continued)\tabularnewline
Methods of language and communication skills evaluation Unstructured
assessment Collection of language samples Unstructured observation of
language and communication functions Structured assessment Formal
standardized assessment Boston Diagnostic Aphasia Examination (BDAE)
Psycholinguistic Assessment of Language Processing in Aphasia (PALPA)
The Comprehensive Aphasia Test (CAT) Bedside Evaluation Screening Test
(BEST) Western Aphasia Battery (WAB) Quick Assessment for Aphasia The
Revised Token Test (RTT) Communicative Activities of Daily Living (CADL)
Boston Assessment of Severe Aphasia (BASA) Reading Comprehension Battery
for Aphasia (RCBA) Aphasia Battery for Adults (ABA) Discourse
Comprehension Test Examining for Aphasia (EFA) Informal/Non-standardized
Assessment Criterion-based assessment Dynamic assessment
Processing-dependent assessment & 0.0 25.0 0.0 25.0 25.0 53.1 65.6 78.1
65.6 \textbf{81.0} \textbf{84.4} \textbf{93.8} \textbf{90.6}
\textbf{90.6} \textbf{90.0} \textbf{96.9} \textbf{96.9} \textbf{96.9}
0.0 9.2 3.1 \textbf{87.5} & 0.0 50.0 0.0 50.0 21.8 28.1 18.8 9.4 28.2
6.0 9.4 0.0 6.2 6.2 6.0 3.1 3.1 3.1 0.0 50.0 9.4 40.6 & \textbf{100.0}
25.0 \textbf{100.0} 25.0 53.1 18.8 15.6 12.5 6.3 12.0 6.2 6.2 3.2 3.2
3.0 0.0 0.0 0.0 \textbf{100.0} 40.7 21.9 37.4 & \textbf{HC} MC
\textbf{HC} MC MC MC MC MC MC \textbf{HC} \textbf{HC} \textbf{HC}
\textbf{HC} \textbf{HC} \textbf{HC} \textbf{HC} \textbf{HC} \textbf{HC}
\textbf{HC} MC IC \textbf{HC}\tabularnewline
Table 3 (continued) & & & &\tabularnewline
Contexts of aphasia evaluation Clinical setting (hospital/center) Social
activities Home/Personal living space & 0.0 18.8 78.1 & 9.4 59.4 12.5 &
\textbf{90.6} 21.8 9.4 & \textbf{HC} MC MC\tabularnewline
\bottomrule
\end{longtable}

Table 4: Percentages of participants according to specific challenges in
aphasia management\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
Challenge in aphasia management & \% (\emph{n})\tabularnewline
\midrule
\endhead
\vtop{\hbox{\strut Cultural-linguistic barriers Differences of dominant
language of PWA versus clinicians}\hbox{\strut Differences of cultural
values of PWA versus clinicians}} & 62.5\% (20) 37.5\%
(12)\tabularnewline
\vtop{\hbox{\strut Support and resource limitations Lack of appropriate
infrastructure}\hbox{\strut Lack of standardized assessment
tools}\hbox{\strut Limited access to continuing education
resources}\hbox{\strut Limited access to trained translators}} & 15.6\%
(5) 62.5\% (20) 21.9\% (7) 9.4\% (3)\tabularnewline
\vtop{\hbox{\strut Clinical competency limitations Lack of knowledge on
updated information}\hbox{\strut Lack of clinical
skills}\hbox{\strut Lack of confidence}} & 50.0\% (16) 37.5\% (12)
34.4\% (11)\tabularnewline
\bottomrule
\end{longtable}

\selectlanguage{english}
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\end{document}

